Rising Cesarean Section Rates in Nepal: Question of Safety and Integrity on Obstetric Emergency Practice

Journal of Gynecology and Women’s Health ISSN 2474-7602 Opinion J Gynecol Women’s Health Volume 7 Issue 4 - November 2017 Copyright © All rights are reserved by Laxmi T DOI: 10.19080/JGWH.2017.07.555716 Rising Cesarean Section Rates in Nepal: Question of safety and Integrity on Obstetric Emergency Practice Laxmi T1*, Goma DNS2, Kumariniraula H2, Roshnitui T3 and Binod A4 1APS Prasuti Tatha Prajanan Swasthya Kendra, Nepal 2Bir Hospital, National Academy of Medical Sciences, Nepal 3Ministry of Health, Nepal 4Department of Obstetrics and Gynaecology, Karnali Academy of Health Science, Nepal Submission: November 14, 2017 ; Published: November 28, 2017 *Corresponding author: Laxmi T, APS Prasuti Tatha Prajanan Swasthya Kendra, Kathmandu, Nepal, Tel: ; Email: Abstract A life-saving obstetric emergency surgical procedure, cesarean section is crucial without its access the large number of pregnant women and includingtheir unborn social babies and dieeconomic every year implications across the would globe challenge especially childbearing in low-income women, countries. babies, The their World families Health and Organization the state. Recently favours in10-15% Nepal therecesarean is a section rate and suggests to be performed only when justified by a medical condition. Otherwise unnecessary health of mother and babies sharp rising trend of cesarean section rates from 20 to 81% in different hospitals particularly in the private setting indicating over-medicalization of childbirthThis arise unnecessarily the issue of performinghuman rights without violence medically of childbearing justified. women and professional integrity of a practitioner and safety of the clients. Growing cesarean delivery rate in Nepal urgently calls for healthcare policy makers and professionals to prospectively investigate and monitor its medical, social and economic implications for the society and the nation. The World Health Organization recommended use of the Robson criteria would be one of the best strategies in reducing the frequency of the procedure that should include avoidance of medically unnecessary primary cesarean section and improving case selection for induction and prelabour cesarean section besides educating childbearing women and their families about the consequences of unnecessary request of the procedure. Keywords: Cesarean section; Violence; Nepal; World health organisation Introduction A cesarean section is life-saving obstetric emergency women to well-documented risks of death, disability and surgical intervention essential when certain complications particularly when not justified by a medical condition, expose depression including increased health costs [3-5]. arise during pregnancy and labour without its access the large number of women and their unborn babies die every year, Many studies have shown that women who have cesarean especially in low-income countries. Nevertheless, the World section without medical necessities are at high risk of higher rates Health Organization (WHO) suggests that no region in the world of infection, pain, pre-hospitalization, breastfeeding challenges, and complications in future pregnancies and even death of [1]. A 2015 WHO statement concludes that cesarean sections are childbearing women [6-13]. Additionally, babies delivered by is justified in having a cesarean section rate greater than 10-15% effective in saving maternal and infants’ lives, but only when they cesarean sections have higher rates of hospital admission, need are required for medically indicated reasons. It states that, at a for ventilation, respiratory morbidity and mortality [6,14-16]. Cesarean section born babies are more likely to have long-term associated with reductions in maternal and newborn mortality negative health effects, such as asthma, type-1 diabetes, obesity, population level, cesarean section rates higher than 10% are not metabolic diseases and lead to unexplained stillbirths in the [2]. Although cesarean is crucial that can save lives, it may also second pregnancy [3,17-20]. These risks explain why cesarean rates, and it should be performed only when medically justified on demand or without any maternal and fetus conditions is lead to significant and sometime permanent complications, J Gynecol Women’s Health 7(4): JGWH.MS.ID.555716 (2017) 001 Journal of Gynecology and Women’s Health considered, an expensive and dangerous luxury, suggesting an medical professionals are becoming perpetrators, which are they urgency of controlling the rate of cesarean sections [21-24]. are unaware of because of own ignorance [32,33]. Despite recommendations and warnings about its risks, A senior consultant obstetrician and researcher of Nepal, cesarean section rates have been constantly increasing across Professor Ganesh Dangal asserts that obstetric violence is the globe, reaching epidemic proportions in some countries, common in Nepal that yet to be researched. Paradoxically, in especially among the urban rich in high, middle and low- rural Nepal women are facing life threating challenge to give income countries and the increase in cesarean rates shows no complicated birth because of lack of access of obstetric emergency signs of slowing down [25-27]. Although multi factorial reasons service where as in urban areas there is a medicalization of implicated in rising cesarean sections rates, however, it has childbirth with unnecessary biomedical intervention treating become a major public health concern and a cause for the debate physiological reproductive processes as biomedical problems as it is recognized as the violence of human rights of childbearing that can be treated by the medical profession [2,34,35]. women. With great concern while enquiring about alarmingly Nepal Context escalating cesarean rates in Nepal some professionals, especially obstetricians assert that women are the one who prefer and Table 1: Percentage of cesarean section in different hospitals of Nepal. request for cesarean delivery. However, studies in different Hospitals, Location Rate settings including Nepal reveal that such assertion has no valid evidence to prove that actually it is because of maternal Om Hospital, Chabahil, Kathmandu request unnecessarily cesarean sections have been performed Medicare Hospital, Chabahil, Kathmandu 81% [36-44]. Moreover, the American College of Obstetricians and Valley Maternity Nursing Home 79% Gynecologists [45] clearly states that cesarean delivery on B & B Hospital 77% maternal request should not be motivated and recommended Nepal Police Hospital, Kathmandu 67% acknowledging the potential risks of the procedure instead in the absence of maternal or fetal indications for cesarean delivery, a Kathmandu Model Hospital 64% plan for vaginal delivery is safe and appropriate and should be Kritipur Hospital (managed by Phect Nepal), 60% Kathmandu recommended for clients. 51% Patan Hospital, Lagankel, Lalitpur Everyone working to improve maternal health care strives Kathmandu Medical College, Sinamangal, Kathmandu 47% towards common goal, healthy mothers, and healthy babies; Civil Service Hospital, New Baneshwor, Kathmandu 46% however, medical model of care can either protect or violate the fundamental human rights of childbearing women. There TU Teaching Hospital, Maharajgunj, Kathmandu 45% is a growing concern among women’s rights and human rights Shree BirendraSainik Hospital (Army Hospital), 39% Kathmandu advocates, and health research professionals regarding over- BP Koirala Institute of Health Science, Dharan 33% medicalization and commercialization of childbirth, particularly in the case of low risk pregnancy and that the cesarean section Nobel Medical College Hospital, Biratangar, Morang 30% rate, recognizing as a violation of human rights in childbirth and Paropakar Maternity and Women’s Hospital (PMWH), 20% Thapathali suggesting for social model of care to empower childbearing Karnali Academy of Health Sciences (KAHS) Teaching 17% women [46]. Hospital, Jumla Conclusion 15% To effectively control the increasing rate of cesarean section NepalWorld (Public Health 12%, Organization Private 35%) 9% In the recent years like in the most middle and10-15% high- policies and measures, such as use of rate of cesarean section in Nepal, the government of Nepal should develop specific income countries there is a rising trend of cesarean births in without medical necessities as one of the hospital’s overall Nepal, especially in urban settings (Table 1). Studies show rating components, and popularizing of natural childbirth. It is that women living in urban, having higher levels of education, essential to educate reproductive age women providing factual on highest wealth quantile and nulliparous are the one who evidence based accurate information on mode of delivery and are going through unnecessary cesarean delivery [28-29]. In its implications. Additionally, use of WHO proposes the Robson some hospitals, for instance, in Patan Hospital and Tribhuvan criteria as a standard for assessing, monitoring and comparing University Teaching Hospital there are growing trend of cesarean cesarean section rates within healthcare facilities overtime, and between facilities would assist in managing cesarean section rates at both the individual facility and national level section rate from 23% in 2005 to 44% in 2014 and 17% in 2005 spontaneous and instrumental vaginal deliveries [30,31]. This to 25% in 2010 respectively indicating declining in normal indicates that unknowingly these women are becoming the subpopulations affects overall cesarean

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